myself to be in line with the best and most recent thought upon the subject, when I speak of it as in greater part at least a mental disease. We are too much inclined to think of nervousness as having a peripheral connotation, and forget that this expression can have nothing to do with the nerves in themselves. When a patient says "I feel nervous," he means exactly what he says. He does not mean that his nerves feel nervous, he means that he feels nervous. He is suffering from a perverted state of personality, and not from a perverted state of this or that nerve, as in neuralgia or multiple neuritis.

By far the greater number of mental disorders of the puerprium lactation, and gestation, arise during that period immediately following child-birth. Kraepaelin says that they constitute seven per cent of admissions to asylums. The frequency of psychoses arising during the puerprium compared to mental disorders of gestation and lactation, has been studied by Schmidt, who finds 17.6 per cent of the whole number of cases arise during pregnancy, 49.3 per cent within six weeks after labor, and 33 per cent during lactation. Hoche's statistics fairly well corroborate these, he finding in the same order, 11.38 per cent, 46.4 per cent, and 42.18 per cent. Paton says that the life period of greatest danger is from the 30th to the 40th year; that cases developing before parturition generally come on during the latter half of pregnancy. The earlier during preg nancy a psychosis appears, the worse is the prognosis, and during the puerprium the days of greatest danger are the third to the sixth.

From what I have said it will readily be seen that to do justice to the title of this paper, would involve the description of many different types of mental disease. This I shall not attempt. To know merely that a mental derangement has developed during gestation, parturition, or lactation, tells us absolutely nothing about it. It may be a dementia praecox, that will prove to be incurable. It may be the maniacal or depressive phase, initiating a maniacal-depressive insanity that will with occasional lucid intervals of a few months, or years' duration, last throughout the patient's ilfetime. On the other hand it may be manifested as confusional insanity, or Meynert's amentia, and with careful treatment result in recovery after a few weeks or months; or it may show itself as a simple neurasthenia, psychasthenia, or hysteria which, under the influence of a rational psychotherapy, will quickly disappear when the strain of childbirth and lactation is past.

When, however, pregnancy or parturition does give rise to a mental illness, if we rule out infection psychoses, our diagnosis most

frequently falls under one of two headings. These I shall briefly discuss.

Furstner, in 1875, described a form of insanity that he thought was dependent upon the puerperal state. From his description the condition he seemed to have in mind is identical with acute confusional insanity, or Meynert's amentia. Almost all of the cases of mental alienation following parturition that have come under my own observation have been of this type, and I believe it constitutes the most frequent psychosis of the puerprium. It seems to be closely related to the hysterical delirium as Ziehen evidently recognized when he gave it the name of paranoia dissociativa, as it is now known that hysteria is essentially a personality dissociation. If I were to attempt to describe this form of puerperal alienation, in two words, I could not do better than to speak of it as a hallucinatory confusion. In fact that is exactly one of the numerous names that have been given it. It is essentially an exhaustion psychosis, and this explains why it so frequently follows parturition. Its distinguishing features are a clouding of consciousness, a great disturbance of idea and memory association, disorientation, motor restlessness, and vivid hallucinations. In fact I do not know of any mental disease which displays such varied, copious, and rich hallucinations as does this. The patient seems to live, so far as sight is concerned, in an imaginary, a dream world. The hallucinations may be pleasant or unpleasant, but they are always vivid. Various illusions of sight are common, as well as hallucinations of hearing. The early symptoms of the disorder, which should excite the physician's suspicions, are restlessness, insomnia, irrelevancy of replies to questions, and a lack of memory for recent events. Sometimes a simple apprehensiveness with vivid and frightful dreams are the first symptoms to be noticed. The restlessness may gradually increase, until a state of intense maniacal excitement is reached, which is often followed by a condition of profound exhaustion and stupor, frequently prophesying a fatal termination. To group the symptoms: We may have first, apprehensiveness, insomnia, distressing dreams, restlessness, confusion of thought, followed by hallucinations and illusions of sight and hearing, incoherency, a high degree of distractibility, maniacal excitement, exhaustion and stupor. This condition, if we care to cling to the old name, since it is the one most frequently following parturition, we may speak of as the typical puerperal mania.

Of all the psychoses which may arise during pregnancy or parturition, the one which I believe to be second in frequency is hysteria. Hysteria is a mental disorder, marked by a contraction of

consciousness, and a dissociation of personality. It is characterized chiefly by a high degree of suggestibility, and the mental and physical states which may arise as a result of such suggestibility. Hysteria is not so much a disease of the waking consciousness as are the true insanities; it is rather a disorder of the subwaking, the reflex self. It is frequently dependent upon the subconscious fixed idea, and the chief etiological factors are different forms of psychic trauma. It is never the direct result of physical conditions in themselves, hence we need not greatly fear it, if our patient is once safely through her confinement. It originates usually during pregnancy, and not infrequently early, the second and third month. The distressing. strong but repressed emotion, usually of fear, cultivates a soil extremely favorable for its development. The onset of pregnancy is distinctly a sexual event, and authorities are united in declaring the repressed sexual emotion to be the prime cause of hysteria. Freund has even gone so far as to lay down the law: "No repressed sexual events, no hysteria." Hence let me caution you, when called to a case of hysteria, never to forget a possible pregnance. Particularly in a suddenly-developing hysteria in a young girl, look for the lover; in other words, suspect the skipped menstruation. However, you should not be in too much of a hurry to diagnose this condition, especially in such as an unmarried girl, because the hysterical fear of pregnancy will in itself suppress the menstrual flow. In fact the hysterical simulation of pregnancy does not stop with the suppressed menstruation; it may cause the morning nausea and vomiting, and is said to have even given rise to a false abdominal enlargement. You must make your differential diagnosis by means of the elicitations of symptoms of the condition with which the patient is unfamiliar, since those with which she is familiar she may unconsciously of course simulate. When pregnancy has been definitely diagnosed, the danger of hysteria is not past, because frequently your patient will indulge in all sorts of morbid and mentally repressed phobias. These often give rise to various other hysterical symptoms with which upon the surface they apparently have nothing to do. If pregnancy is safely passed, the pains and stress of parturition are still able to throw the patient into a hysterical state. One such case was recently brought to my attention. A young married woman in labor just before the last expulsive pains suddenly seemed to lose her mind completely. In other words she fell into what was in all probability a grave hysterical delirium. The condition was never definitely diag nosed, but as she failed to improve she was sent to the asylum. There was no change for a number of years, until in the hope that

the operation might be of some benefit, she was chloroformed for the purpose of releasing an adherent clitoris. As she awoke from the anesthetic, her first words were, "Where's my baby?" Her baby was at that moment an attractive little girl eight years of age. She had no return of her mental symptoms, but she never recovered a memory of her eight long years of delirium.

To at all adequately discuss the treatment of mental derangements, incident to pregnancy and the puerprium, would, since any form of alienation may be initiated by these states, involve the writing of a work on psychiatry. Since you are not alienists but practical obstetricians, it is more important that I should speak to you of prophylaxis.

The most important element in the prophylaxis is that you should see the expectant mother at relatively frequent intervals during her gestation. The necessity that she bring in a sample of urine, use as an excuse for the encouragement of occasional office visits; then during a friendly chat you will be able to quickly discover her mental condition, and remove any fears or false ideas that may be taking shape in her mind. She should be encouraged to think that her labor will be easy and normal, and even where the pregnancy has at first been an unwelcome one, you will frequently find yourself able to so alter her state of mind that she will look forward with pleasure to the arrival of her child. If your patient happens to be unmarried, you should be particularly tactful and sympathetic. Do not drive her to the abortionist by the brusque refusal to do any thing for her. Do not indulge in moral lectures which will only aggravate her already distracted mental condition. Show her as best you can that the safest course is for her to see the affair bravely through. Impress her with the dangers of abortion, and insist upon the ease and safety of a natural parturition. Secure her permission to consult with her father or mother, and point out to them that their daughter is in need of sympathy and not condemnation. Then arrange for the convenient trip to Europe or a distant city.

The prophylaxis of the psychoses taking their rise during the puerprium consists chiefly in close attention to your patient's physical condition during pregnancy, and the careful management of the case during parturition. The patients of the best obstretician have the least trouble, mental and physical. Not being an obstetrician, it would be presumptuous in me to attempt to remind you of methods for facilitating labor, and minimizing its pains. But never forget the friendly counsel and encouragement so necessary in this of all bedside situations. Guard against the excessive loss of blood or the

very prolonged labor. The mental anguish incident to physical pain should be lessened by the judicious use of chloroform, and its psychic stress should be ended by the timely application of the forceps. Many of you no doubt have your own ideas upon the use of the forceps and chloroform, but I am speaking to you from the standpoint of the neurologist. I believe that if there were a freer, yet still careful, use of this anesthetic at the bedside of the parturient woman, we would observe fewer hysterical deliria following confinement, and race suicide would not be so popular.

Some authorities

recommend hypnosis as a substitute for chloroform. I have had no experience with hypnosis during accouchment, but theoretically it is the ideal method of abolishing its pains and mental stress. It can do no harm if judiciously used. Should you attempt to hypnotize your patient for the first time during labor, you will fail because you will not be able to secure the necessary concentration of attention. If however, by means of three or four previous seances, you are able to teach her to fall asleep, at your word of command, you will have no difficulty in inducing the state even during the most painful stage of parturition. The technic, however, of course, must first be mastered. As the laity gradually become educated away from the idea that hypnotism is something dangerous or mysterious, I believe this method of facilitating and abolishing the pains of parturition will be more frequently made use of.

Now to briefly summarize: There is no mental disorder with a definite relation to pregnancy or the puerprium. These states may however act as the initiating factors of any form of psychic derangement, particularly when conception takes place in a woman who is not mentally or physically fitted for the ordeal. Owing to the stress of modern civilization, many women must face pregnancy and the puerprium without proper foundation in physical health. The fact that in the human female, child-bearing, coming within the sphere of consciousness, introduces the psychic element, was called attention to. While disturbed mental states incident to pregnancy and the puerprium may take any form of mental alienation, they usually take one of two forms. The first acute confusional insanity results from the physical exhaustion of parturition, the second hysteria in its infinite. variety is dependent upon the psychic trauma incident to these states. In hysteria we should suspect pregnancy; during pregnancy we should guard against hysteria.

Prophylaxis is of the greatest importance. This is secured by a careful attention to your patient's physical and mental condition. during pregnancy, and by the efficient and humane management of